Provider Demographics
NPI:1346455425
Name:CADAVID SEPULVEDA, JUAN CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:CADAVID SEPULVEDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 NORTHSIDE BLVD STE 3500
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-8223
Mailing Address - Country:US
Mailing Address - Phone:770-292-3120
Mailing Address - Fax:770-292-3121
Practice Address - Street 1:1505 NORTHSIDE BLVD STE 3500
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-8223
Practice Address - Country:US
Practice Address - Phone:770-292-3120
Practice Address - Fax:770-292-3121
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA068126207RC0200X, 207RP1001X
PAMD 438781207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003126963BMedicaid
GA202I299550Medicare PIN